Medicinal Value of Humor

The History of Humor in Medicine

The application of humor and laughter to relieve pain is hardly a new concept. References to the value of laughter in medicine can be traced back to biblical times, as Proverbs 17:22 states “a merry heart doeth good like a medicine.”

For centuries, philosophers and scientists alike have investigated the positive health benefits associated with laughter. In 1709, in “An Essay on the Freedom of Wit and Humor,” Lord Shaftesbury explained laughter as the emancipation of “animal spirits” that have amassed within nerves.(1) This philosophy was the foundation for the “relief theory,” which suggested that laughter releases the pressure of repressed nervous energy.(2) Even as the nervous system became better understood over the next two centuries, however, the relief theory was not discarded. Philosophers Herbert Spencer and Sigmund Freud both used the relief theory in the context of new biological discoveries.(3,4)

In his 1927 essay “Humor,” Freud described laughter’s liberating effects, theorizing that laughter “relieves anxiety or repressed impulses.”(5) This ideology later translated to gallows humor, a macabre type of humor invoked in circumstances of death or traumatic stress.(5)

Norman Cousins became an advocate for the healing powers of humor when he published Anatomy of an Illness as Perceived by the Patient: Reflections on Healing and Regeneration. In 1964, Cousins was diagnosed with debilitating and terminal ankylosing spondylitis, and doctors predicted that he had only a few months to live.(6,7) In his book, Cousins recounted how he cured himself from all ailments by daily intervals of laughter and large doses of vitamin C.(5) Cousins’ use of therapeutic laughter resulted in painless sleep and a reduction of his erythrocyte sedimentation rate.(6) Later, Cousins attributed his recovery to laughter’s reduction of panic, rather than to any effect it might have on biochemical recuperation.(6) Nonetheless, scientists were now encouraged to investigate biochemical alterations of therapeutic humor.(6)

Mechanisms of Laughter and Illness

In investigating the medicinal benefits of humor and laughter, it is important to consider whether humor and laughter treat illness by promoting immuno-enhancement, or whether they merely act as a distraction, masking symptoms that are still present.

Dr. William Fry, a professor of psychology at Stanford University, coined the word gelotology, meaning the study of laughter. In his research into laughter and healing, Fry used a pulse oximeter to track changes in oxygen saturation in patients who experienced three minutes of continuous laughter. Although laughter did not seem to affect oxygen saturation, it did result in increased ventilation, increased muscle activity, and the creation of forceful exhalation that could mobilize and remove pulmonary secretions.(8)

Humor has proved valuable in managing adults with various medical conditions.

Fry’s research led him to publish multiple studies of the physiological processes that occur during laughter. Fry said, “I believe that we do not laugh merely with our lungs, or chest muscles, or diaphragm, or as a result of a stimulation of our cardiovascular activity. I believe that we laugh with our whole physical being. I expect that this total participation will eventually be recognized.(9)

Humor and the Immune System

Numerous studies have investigated the effect of humor on immune function by examining levels of salivary immunoglobulin A (S-IgA), a substance found in saliva that aids in immunity against upper respiratory infections. Several early studies have shown a positive correlation between levels of S-IgA and self-reported sense of humor score. However, these analyses were of small sample size, and the findings failed replication when tested again with a larger sample size.(10)

Humor has proved valuable in managing adults with various medical conditions. In patients with chronic obstructive lung disease (COPD), for example, hyperinflation was reduced with exposure to humorous content. Although the results must be corroborated by follow-up studies, the improvement in patients with COPD could be attributed to a “smile-derived breathing technique.” This type of breathing could accompany pursed-lips breathing and overall provide some relief to patients with symptomatic airway obstruction. The results indicate a positive role of induced laughter in people affected by severe to very severe COPD, because laughter can be employed anywhere at any time, at no cost to the affected person.(11)

Humor and Blood Pressure

The act of laughing employs two physiologic elements: respiratory activity and muscle activity. Many studies have taken this into consideration and explored laughter’s impact on blood pressure due to mechanical and hydrodynamic changes.(6) These studies attempted to confirm the widespread speculation that frequent laughter gradually reduces blood pressure. Experiments have shown short-term increase in blood pressure post-laughter, with no long-term effect.(10) However, a study by Fry and Savin using audio and video stimulation to evoke laughter displayed a sharp increase in systolic and diastolic blood pressure, followed by a gradual decrease of blood pressure below prestimulation levels.(6,12)

In a correlational study conducted by Lefcourt et al., a difference between sexes was apparent when researchers compared sense of humor test scores and systolic blood pressure.(13) Subjects were instructed to complete a number of stressful laboratory tasks. The results for women showed a negative correlation between sense of humor and systolic blood pressure, whereas the men’s results displayed an opposite effect. The experimenters attributed this sex difference to possible differences in ways men and women express humor.(10)

Humor and Pain Tolerance

Many researchers have sought to test laughter’s analgesic effects on subjects’ pain tolerance, with results of these studies providing evidence that exposure to comedic material increases a subject’s pain tolerance. Most of these studies controlled for distraction, relaxation, and other factors. Although the results of these studies were consistent, it remains unclear whether an increase in pain threshold was due to the overt act of laughter, or to an effect of the positive emotions associated with comedy and humor. When subsequent studies were conducted with negative-emotion control, however, invoking feelings such as disgust, horror, and sadness, the results of these studies also—surprisingly—showed an increase in pain tolerance. Overall, researchers concluded that the increase in pain tolerance observed is due to the effects of emotional arousal and is not specific to laughter or cognition of comedic amusement.(10)

Laughter in the medical setting has been shown to decrease the perception of pain and increase pain thresholds.

In many cases, the ability to tolerate pain may be enhanced after exposure to humorous movies. In an experiment by Rotton and Shats,(14) the healing powers of humor were studied with postsurgical patient’s need for pain medication. No effect was noted on the first postoperative day, but the experimental group showed a 61% decrease in requests for minor analgesics (e.g., aspirin, minor tranquilizers) on the second day after surgery. Interestingly, patients who did not have control over which movie they watched experienced no improvement compared with the control group. This suggests that for the humor to have a positive effect on pain control, patients must be active participants in the type of material selected.

Laughter in the medical setting has been shown to decrease the perception of pain and increase pain thresholds. British experimental studies showed that as a result of the release of endorphins, pain thresholds were significantly higher after laughter than in the control situation. Furthermore, the results confirmed that an increase in pain threshold was due to the act of laughter, and not an outcome of a participant’s positive affect.(15) Similarly, a study at the University of California—Los Angeles indicated that children and adolescents showed significantly greater pain tolerance while watching funny videos. Although further study is required to demonstrate the mechanism of this effect, humorous distraction definitely was beneficial to youth undergoing painful procedures.(16)

Humor and Stress Reduction

To evaluate laughter’s effect on stress reduction, Toda et al. focused on the biologic stress marker salivary chromogenin A (CgA)(17). CgA is a neuroendocrine acidic glycoprotein secreted by submandibular salivary glands in saliva. Levels of CgA show exclusive correlation with mental stress and have no association with physical stress. Toda et al. exposed 11 subjects to either 30 minutes of landscape scenes or a comedy show over multiple days. By measuring the quantity of CgA in saliva before and after the experiment, Toda et al. found that the subjects exposed to the landscape scenes had no significant change in CgA levels. In contrast, those exposed to the comedy show did show an increase in CgA levels in their saliva. Toda et al. concluded that higher levels of CgA post-laughter may be a result of positive stress. The evaluation of the subjective stress perception after experimentation backed this conclusion.(6)

Humor and clowning have demonstrated improvement in children with respiratory tract infections.

In children, humor has been shown to reduce preoperative anxiety and their experience of pain during invasive procedures such as venous blood draws, urologic surgery, and allergy skin testing. Humor and clowning have demonstrated improvement in children with respiratory tract infections. Another benefit of humor is to reduce the stress and anxiety experienced by parents of pediatric patients.(16)

Another study demonstrating the value of humor was conducted in Israel in an in vitro fertilization (IVF) clinic. A study used clowns to interact with women following in vitro fertilization. Interestingly, the study demonstrated those women who had access to medical clowning had more successful fertility treatments and increased pregnancy rates. Perhaps the improvement was due to stress reduction produced by the use of humor and medical clowning. Stress reduction might improve fertility, resulting in positive effects on engraftment.(18)

Humor’s effect in stress reduction has been attributed to a reduction in cortisol levels, the hormone associated with stress. To determine whether humor can be beneficial in the treatment of anxiety, the impact of a humorous stimulus on anxiety and heart rate was investigated with q group of 53 undergraduate college students. In this laboratory study, subjects were falsely told that they would receive a shock in 12 minutes. The participants were classified as having either a low or high sense of humor, as evaluated by the Situational Humor Response Questionnaire developed by Martin and Lefcourt.(19) The participants were placed into three different groups while awaiting the shock, in which subjects listened to either a humorous recording, a non-humorous recording, or no recording. Participants exposed to the humorous tape reported less stress and anxiety compared with the other two groups. By measuring zygomatic facial activity, the researchers found that the subjects with a high sense of humor and the subjects exposed to the humorous tape showed more smiling than the other participants.(20)

Humor and Depression

Early evidence recently has surfaced that indicates that humor may play a role in lifting depression. A 2006 study compared the impact of pharmacologic medication and humor group therapy to standard medication treatment alone in elderly patients with late-onset depression and Alzheimer disease. The humor group received a one-hour humor therapy session every two weeks. In this pilot study, no significant difference was seen between humor therapy and standard therapy on overall quality of life. However, the humor intervention can be an additional tool to relieve geriatric and psychiatric patients from their depression.(21)

Another study conducted on clinically depressed outpatients used both humor and paradoxical intent (the deliberate practice of a neurotic habit or thought, undertaken to identify and remove it). This intervention was found to be successful for most of the 80 group participants who succeeded in overcoming depression symptoms, as determined by achieving some success in either the discontinuation of medication, obtaining a job, or establishing a positive relationship or friendship.(22)

Humor in Practice

We suggest putting humor on your horizon. Find a few simple items, such as photos, greeting cards, or comic strips, that make you chuckle. Then hang them up at home or in your office. Keep funny movies, books, magazines, or comedy videos on hand for when you need an added humor boost. Look online at joke websites, such as www.rd.com/jokes/ from Reader’s Digest.

Laugh and the world laughs with you. Find a way to laugh about your own situations and watch your stress begin to fade away. Even if it feels forced at first, practice laughing. It does your body good. Remember, take your work—but not yourself—seriously.

Bottom Line: Medicine is on the cusp of learning how humor and laughter can influence our health and wellness. Although the evidence is not in, and not all of the studies are convincing, there is no doubt that humor can be beneficial to our patients. The good news is that humor is inexpensive—it is free, readily available, and has no known side effects, no known risk factors, and has not shown to be harmful in any way. As the philosopher Bertrand Russell once said: “Laughter is the most inexpensive and most effective wonder drug.” Perhaps as physicians and healthcare workers, we should write a prescription for humor not only for our patients but also for ourselves. Just think, laughter is no joking matter.

References

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2. Morreall J, ed. The Philosophy of Laughter and Humor. Albany: State University of New York Press; 1987.

3. Spencer H. On the physiology of laughter. In: Essays on Education, Etc. London: Dent; 1911.

4. Freud S. Jokes and Their Relation to the Unconscious. Harmondsworth: Penguin; 1976.

5. Bennett MP, Lengacher C. Humor and laughter may influence health: III. Laughter and health outcomes. Evid-Based Compl Alt. 2008;5(1):37-40. DOI:10.1093/ecam/nem041.

6. Noureldein MH, Eid AA. Homeostatic effect of laughter on diabetic cardiovascular complications: the myth turned to fact. Diabetes Res Clin Prac. 2018;135:111-119. DOI:10.1016/j.diabres.2017.11.014.

7. Trussell T. Healing humor. The Saturday Evening Post. 2008;Jul-Aug:36-88.

8. Savage BM, Lujan HL, Thipparthi RR, DiCarlo SE. Humor, laughter, learning, and health! A brief review. Adv Physiol Educ. 2017;41:341-347.

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10. Martin RA. Is laughter the best medicine? Humor, laughter, and physical health. Curr Dir Psychol Sci. 2002;11(6):216-220. DOI:10.1111/1467-8721.00204.

11. Brutsche MH, Grossman P, Müller RE, et al. Impact of laughter on air trapping in severe chronic obstructive lung disease. Int J Chron Obstruct Pulmon Dis. 2008;3(1):185-192. DOI:10.2147/copd.s2204.

12. Fry WF, Savin WM. Mirthful laughter and blood pressure. Humor. 1988;1:49–62. https://doi.org/10.1515/humr.1988.1.1.49 .

13. Lefcourt HM, Davidson K, Prkachin KM, Mill DE. Humor as a stress moderator in the prediction of blood pressure obtained during five stressful tasks. Journal of Research in Personality. 1997;31:523-542.

14. Rotton J, Shats M. Effects of state humor, expectancies, and choice on postsurgical mood and self-medication: a field experiment1. J Appl Soc Psychol. 1996;26:1775-1794. DOI:10.1111/j.1559-1816.1996.tb00097.x.

15. Dunbar RI, Baron R, Frangou A, et al. Social laughter is correlated with an elevated pain threshold. Proc Biol Sci. 2011;279(1731):1161-1167. DOI:10.1098/rspb.2011.1373.

16. Stuber M, Hilber SD, Mintzer LL, Castaneda M, Glover D, Zeltzer L. Laughter, humor and pain perception in children: a pilot study. Evid-Based Compl Alt. 2009;6:271-276. DOI:10.1093/ecam/nem097.

17. Toda N, Nakanishi-Toda M. How mental stress affects endothelial function. Pflügers Archive-European Journal of Physiology. 2011;462:779-794.

18. Friedler S, Glasser S, Azani L, et al. The effect of medical clowning on pregnancy rates after in vitro fertilization and embryo transfer. Fertil Steril. 2011;95:2127-2130. DOI:10.1016/j.fertnstert.2010.12.016.

19. Martin RA, Lefcourt HM. Situational humor response questionnaire: quantitative measure of sense of humor. Journal of Personality and Social Psychology. 1984;47(1):145-155. DOI:10.1037//0022-3514.47.1.145.

20. Yovetic NA. Benefits of humor in reduction of threat-induced anxiety. Psychol Rep. 1990;66(1):51-58. DOI:10.2466/pr0.66.1.51-58.

21. Walter M, Hänni B, Haug M, et al. Humour therapy in patients with late-life depression or Alzheimer’s disease: a pilot study. Int J Geriatr Psych. 2006;22(1):77-83. DOI:10.1002/gps.1658.

22. Roller B, Lankester D. Characteristic processes and therapeutic strategies in a homogeneous group for depressed outpatients. Small Group Behav. 1987;18:565-576. DOI:10.1177/104649648701800410.